a review of acute stress disorder in dsm-5

Review

DEPRESSION AND ANXIETY 28 : 802–817 (2011)

A REVIEW OF ACUTE STRESS DISORDER IN DSM-5

Richard A. Bryant, Ph.D.,� Matthew J. Friedman, M.D., David Spiegel, M.D., Robert Ursano, M.D.,and James Strain, M.D.

Acute stress disorder (ASD) was introduced into DSM-IV to describe acute stressreactions (ASRs) that occur in the initial month after exposure to a traumaticevent and before the possibility of diagnosing posttraumatic stress disorder(PTSD), and to identify trauma survivors in the acute phase who are high riskfor PTSD. This review considers ASD in relation to other diagnostic approachesto acute stress responses, critiques the evidence of the predictive power of ASD,and discusses ASD in relation to Adjustment Disorder. The evidence suggeststhat ASD does not adequately identify most people who develop PTSD. Thisreview presents a number of options and preliminary considerations to beconsidered for DSM-5. It is proposed that ASD be limited to describing severeASRs (that are not necessarily precursors of PTSD). The evidence suggests thatthe current emphasis on dissociation may be overly restrictive and does notrecognize the heterogeneity of early posttraumatic stress responses. It is proposedthat ASD may be better conceptualized as the severity of acute stress responsesthat does not require specific clusters to be present. Depression and Anxiety28:802–817, 2011. rr 2010 Wiley-Liss, Inc.

Key words: acute stress disorder; posttraumatic stress disorder; DSM-V

Acute stress disorder (ASD) was introduced in DSM-IVas a new diagnosis to describe acute stress reactions(ASRs) that may precede posttraumatic stress disorder(PTSD). In the prelude to DSM-5, it is appropriate toreview the utility of ASD as a diagnosis and to determinethe extent to which it adds value to the current diagnosisof PTSD. The ASD diagnosis was introduced for twoprimary reasons: to describe ASRs that occur in theinitial month after trauma exposure, which have earliergone unrecognized or were labeled adjustment disor-ders,[1] and to identify trauma survivors who are high riskfor developing subsequent PTSD.[2] At the time of itsintroduction, there was far less evidence than we havenow to support the definition of the diagnosis.[3] Thisreview addresses (a) the definition of ASD, (b) thedistinction between ASD and ASRs, (c) the overlapbetween ASD and Adjustment Disorder, (d) the capacityof ASD to predict subsequent PTSD, (e) the role ofdissociation in ASD, (f) the benefits of the ASD toenhance early intervention, (g) the range and utility ofemotional responses in the A2 definition, (h) cross-cultural considerations for ASD, (i) the utility of an ASDdiagnosis, and (i) finally, a proposal for the modified ASDdefinition in DSM-V. This article was commissioned bythe DSM-5 Anxiety, Obsessive–Compulsive Spectrum,

Post-Traumatic, and Dissociative Disorders Work Group.It represents the work of the authors for considerationby the work group. In the course of this review, theDSM-IV Source Book and DSM-IV Options Bookwere also reviewed. Recommendations provided in thisarticle should be considered preliminary at this time;they do not necessarily reflect the final recommenda-tions or decisions that will be made for DSM-5, as theDSM-5 development process is still ongoing. It ispossible that this article’s recommendations will be

Published online 3 November 2010 in Wiley Online Library

(www.wileyonlinelibrary.com).

DOI 10.1002/da.20737

Received for publication 20 March 2010; Revised 24 June 2010;

Accepted 24 June 2010

�Correspondence to: Richard A. Bryant, School of Psychology,

University of New South Wales, N.S.W., 2052, Australia.

E-mail: [email protected]

The authors report they have no financial relationships within the

past 3 years to disclose.

School of Psychology, University of New South Wales, New

South Wales, Australia

rr 2010 Wiley-Liss, Inc.

revised as additional data and input from experts andthe field are obtained.

DEFINITION OF ACUTE STRESSDISORDER

Table 1 presents the DSM-IV criteria for ASD. Theprimary difference between ASD and PTSD is theduration of the symptoms and the former’s emphasis ondissociative reactions to the trauma. ASD refers tosymptoms manifested during the period from 2 days to4 weeks posttrauma, whereas PTSD can only bediagnosed from 4 weeks. In terms of dissociation, thediagnosis of ASD requires that the individual has atleast three of the following: (a) a subjective sense ofnumbing or detachment, (b) reduced awareness of one’ssurroundings, (c) derealization, (d) depersonalization,or (e) dissociative amnesia. There are other additional,albeit minor, differences, which mainly involve lessstringent requirements to meet ASD avoidance andarousal clusters relative to PTSD. Whereas PTSDrequires three avoidance or numbing symptoms andtwo arousal symptoms, the ASD criteria require‘‘marked’’ avoidance and arousal. Accordingly, it ispossible for an individual to satisfy criteria for ASD andto not satisfy PTSD diagnostic criteria after 1 monthhas transpired, even if the symptomatology hasremained unchanged. For example, an individual mayhave satisfied ASD diagnosis by displaying markedavoidance and arousal symptoms but may not have met

the PTSD criteria for multiple symptoms within eachcluster. This inconsistency could result in individualsatisfying criteria for a psychiatric disorder at 3 weeksposttrauma but not receiving a diagnosis 2 weeks later.This is not necessarily problematic if one conceptua-lizes these two disorders as distinct responses (acuteversus chronic stress reactions).

DISTINCTION BETWEEN ASDAND ACUTE STRESS REACTIONS

One of the goals of ASD was to describe ASRs.There is much evidence in the literature of a range ofdistressing responses in the aftermath of trauma,including posttraumatic anxiety, mood disturbances,sleep problems, aggression, substance abuse, and manyother physical and psychological symptoms.[4,5] Thatis, by focusing on acute posttraumatic stress reactions,the ASD diagnosis does not encompass a broader arrayof psychological reactions that commonly occur andcan be as distressing as ASD responses. For example,despite not yet being formally recognized as apsychiatric disorder, prolonged grief may develop aftertraumatic loss with documented adverse mental healthoutcomes.[6] This condition is currently recognized 6months after the loss because most bereaved indivi-duals adapt during this time.[7] Before that time,however, and certainly within the initial month, manybereaved people suffer intense grief reactions.

Despite the broad range of emotional reactionsreported by trauma survivors in the acute phase,ASD is conceptualized in DSM-IV as on the onehand depicting an array of relatively common patho-logical acute responses to trauma, and yet alsoconstrained by symptom similarity as a precursor toPTSD. Accordingly, it has focused on anxiety anddissociative responses. There is strong evidence thatthe symptoms reported in ASD are common in theaftermath of trauma, including re-experiencing[8,9] andavoidance.[10,11] Arousal symptoms are also common,including insomnia,[10,12,13] concentration deficits,[10,11]

irritabilty,[12] and agitation.[12,13] A criticism of thecurrent focus of ASD on anxiety responses is that itneglects other early distressing emotional reactions,including depression, guilt, shame, anger, disgust, shock,or somatic reactions.[5] In the current diagnostic system,these reactions—which may be as impairing as fear/anxiety responses—may be diagnosed as AdjustmentDisorder when they contribute to marked impairment.

The theoretical position that underlies the DSM-IVconceptualization of ASD can be contrasted with thedescription of ASRs in the tenth edition of theInternational Classification of Diseases.[14] Instead of beingconsidered a precursor of subsequent psychopathology,the ICD-10 conceptualizes ASR as a transient reactionthat can be evident immediately after the traumaticevent and usually resolves within 2–3 days after atrauma. The ICD description of ASR includes primarily

TABLE 1. DSM-IV-TR diagnostic criteria for ASD

A1. Exposure to catastrophic stressorA2. Intense emotional reaction to stressorB. During or after experiencing the distressing event, the individual

has three (or more) of the following dissociative symptoms(1) Sense of numbing, detachment, or absence of emotional

responsiveness(2) Reduction in awareness of surroundings (e.g., ‘‘being in a daze’’)(3) Derealization(4) Depersonalization(5) Dissociative amnesia

C. The traumatic event is persistently reexperienced in at least oneof the following ways: recurrent images, thoughts, dreams,illusions, flashback episodes, or a sense of reliving the experience;or distress on exposure to reminders of the traumatic event

D. Marked avoidance of stimuli that arouse recollections of thetrauma (e.g., thoughts, feelings, conversations, activities, places,people)

E. Marked symptoms of anxiety or increased arousal (e.g., difficultysleeping, irritability, poor concentration, hypervigilence,exaggerated startle response, motor restlessness)

F. The disturbance causes significant distress or impairmentG. The disturbance lasts for a minimum of 2 days and a maximum of

4 weeks and occurs within 4 weeks of the traumatic eventH. Disturbance is not due to the effects of substance use or medical

condition or is not better accounted for by brief psychoticdisorder, and is not merely an exacerbation of a preexisting Axis Ior II disorder

803Review: Acute Stress Disorder

Depression and Anxiety

dissociative (daze, stupor, amnesia) and anxiety (tachy-cardia, sweating, flushing) reactions. Some commentatorshave suggested that this wide-ranging description maybe more useful for clinicians than the more focusedDSM-IV criteria.[5,15] This approach allows for theconsideration of acute distress which may warrantintervention (e.g., sleep disturbance) but does notattempt to predict subsequent disorder. Further, ASRnotes that the very initial period after trauma exposuremay result in a rather amorphous distress state thatencompasses many emotional responses that cannot bereadily classified into different responses.[16] In thesubsequent period, responses may crystallize into moreclassifiable responses, such as anxiety or mood reac-tions.[17] Although there is some evidence that peoplewho suffer ASR are more likely to suffer persistentpsychological reactions beyond 48 hr,[18,19] this knowledgebase is very limited. By definition, ASR occurs beforeASD can begin—the first 48 hr. ASD covers the timeperiod from 48 hr to 1 month, when PTSD could begin.Thus, those whose symptoms persist or start after 48 hrmay represent a different group of trauma responders.

Related to ASR is the construct of combat stressreactions (CSR). This is a similar construct to ASR,except that it is not time-limited. This classification candescribe combat personnel who are not able to functionat any point after being exposed to severe stress in thecourse of combat. This construct has a very longhistorical tradition in military circles as a means todescribe the broad range of psychological responses inthe immediate and longer term periods followingcombat.[1] One important difference of CSR in contrastto ASD and ASR is that there is no requirement offunctional impairment, which may lead to overidenti-fication of people in need of mental health services.[2]

There are longer term follow-up studies of CSRpersonnel, and these tend to report statistically higherrates of PTSD and dysfunction in those with initialCSR.[20] Despite this relationship, there is a dearth ofevidence about the specificity of CSR to predictsubsequent PTSD.

DISTINCTION BETWEEN ASDAND ADJUSTMENT DISORDERAdjustment disorder currently describes a broad

range of psychological responses to a stressful event(that may not necessarily be traumatic). Theseresponses can occur immediately after the event, andalthough it has traditionally been regarded as a short-term adjustment problem, there is also provision forthe diagnosis to be made when the person has chronicimpairment secondary to the consequences of theevent. It is distinguished from ASD in several ways.First, whereas ASD is limited to fear/anxiety responses,Adjustment Disorder encompasses all forms of distres-sing responses (e.g., depression, anger, guilt). Second,although Adjustment Disorder is predictive of

subsequent impairment,[21] the disorder intentionallydescribes current dysfunction and it does not containthe explicit goal of identifying people who will suffersubsequent impairment. Third, whereas ASD can bediagnosed from 2 days after the event up to 1 month,Adjustment Disorder can be diagnosed immediatelyafter the event. It should be noted that AdjustmentDisorder can have broad clinical utility because itallows a clinician to describe the various psychologicaldisturbances that a person may be experiencing in theimmediate aftermath of an aversive event. For example,after the New York terrorist attacks of 9/11, clinicianswere able to offer many survivors formal mental healthcare by describing their diverse reactions with Adjust-ment Disorder. Thus, Adjustment Disorder in DSM-IV can be used, by temporal definition, to coversituations described as ASR (F43.0) in ICD-10,whereas ASD cannot.

A limitation of Adjustment Disorder is that its broaddefinition has not resulted in focused treatmentinterventions to alleviate the condition. One potentialadvantage of ASD is that it has identified a specificform of initial adjustment difficulties that occur in theacute phase of trauma that is distinguished by itssymptom structure and is amenable to early interven-tions. That is, whereas most difficulties that aredescribed by the Adjustment Disorder diagnosis arediverse, poorly defined, and not specific to a treatmentintervention, ASD has allowed the identification of ananxiety-based acute response that responds positivelyto treatment.

PREDICTIVE UTILITY OF ASDOF SUBSEQUENT PTSD

As noted above, one goal of the ASD diagnosis was toidentify people in the initial month following traumaexposure who are not experiencing a transient stressreaction, but rather display severe acute responses andthe prodromal symptoms of PTSD. To evaluate thecapacity of ASD to identify people who are at high riskfor PTSD development, Bryant recently conducted asystematic analysis of the literature of prospectivestudies of ASD and PTSD by searching PsycINFO,MEDLINE, PubMed, and PILOTS for English-language articles published between 1994 and 2009using keywords that combined ASD and stress disorders/PTSD. Studies were then included if they assessed ASDwithin 1 month of trauma exposure and prospectivelyfollowed the same participants over time to assessPTSD diagnosis. Inclusion required studies to usemeasures of ASD and PTSD that permitted diagnosticprevalence rates based on DSM-IV criteria. Twenty-twostudies were identified that assessed ASD withina month of trauma exposure and determined therelationship between ASD and subsequent PTSD;[22–43]

19 with adults and 3 with children (a detailed report ofthis analysis is reported elsewhere[44]).

804 Bryant et al.


The rates of full ASD ranged from 7 to 28%, with amean rate of 13%. It is noteworthy that a proportion ofthese studies have also reported the prevalence ofsubsyndromal ASD, which is typically defined assatisfying at least three (typically not requiring thedissociative criterion) of the symptom clusters. Includingsubsyndromal cases of ASD, together with cases thatmeet full ASD criteria results in markedly higher ratesof identified cases, with the range from 10–32% and amean of 23%. Across some of these studies, the rates oftrauma survivors displaying acute stress are increasedprimarily by not requiring the dissociative criteria to bemet. Bryant’s review of these studies reported that thepositive predictive power of studies was moderatelystrong, with most studies of adults indicating that atleast half of those trauma survivors with ASD meetingcriteria for subsequent PTSD.[44] These studies suggestthat people who do meet criteria for ASD are at higherrisk for persistent PTSD. In contrast, the sensitivityacross most studies was poor, indicating that themajority of trauma survivors who eventually developedPTSD did not meet the full criteria for ASD.Specifically, the 22 identified studies included follow-up assessments of 3,335 individuals. Although 497 ofthese trauma survivors met criteria for PTSD at thefollow-up assessment, only 238 (48%) of theseindividuals had met criteria for ASD in the monthfollowing trauma exposure. This suggests that if amajor goal of ASD is to predict people who willsubsequently develop PTSD, it is failing to identify halfof those who will meet criteria for PTSD at some latertime. In some cases, this may be because significantpsychopathology simply does not emerge until later. Inother cases the ASD criteria may lack sufficientsensitivity.

Some studies reported data that permitted calcula-tion of the predictive capacity of subsyndromal ASD,defined as satisfying only three of the ASD symptomclusters (often by omitting the requirement thatdissociation be present). Overall, these analyses in-dicate that the sensitivity is generally better when oneadopts a subsyndromal approach. That is, by focusingon general posttraumatic stress symptoms rather thanemphasizing dissociation, more people who eventuallydevelop PTSD can be identified in the acute phase.This pattern may be explained, in part, by the fact thatthe re-experiencing, avoidance, and arousal clusters inASD match onto the same symptom clusters in PTSD,whereas dissociation encompasses a different symptomset that is not as strongly represented in the PTSDdiagnostic criteria. This approach resulted in signifi-cant proportions of trauma survivors who developedPTSD not being identified in the acute phase. It shouldalso be noted that the relationship of ASD to otherlater occurring psychiatric disorders has been lessstudied (e.g., depression, alcohol use, prolonged grief).

Recent research developments have identified a rangeof peritraumatic markers of high risk for PTSD thatmay facilitate identification of acutely trauma-exposed

people who may benefit from early intervention. Thisresearch has extended beyond the ASD diagnosis indifferent ways to improve prediction of subsequentPTSD. Numerous studies indicate that people whodevelop PTSD have higher heart rates immediatelyafter trauma than those who do not develop PTSD.[45]

A comparable pattern has been found for acuterespiration rate.[46] Numerous studies have found thatmaladaptive appraisals about oneself and one’s environ-ment is strongly predictive of subsequent PTSD.[47–49]

Other approaches have adopted a broader frameworkand assessed pretrauma, peritraumatic, and posttraumarisk factors that potentially predict PTSD. For example,one screening measure was developed that includeditems about psychiatric history, perceived level ofthreat, and access to social support, and was found tousefully predict PTSD.[50] These developments under-score the point that there are potentially better meansto identify people at risk for PTSD development thanan acute diagnosis. However, although such biomarkersare of considerable research interest, they have not beenemployed successfully to correlate or predict diagnosis.

ROLE OF DISSOCIATION IN ASDA cornerstone of the current ASD diagnosis is that

the survivor has at least three dissociative symptoms.From a theoretical perspective, this position wasinfluenced by the view that dissociative responses inthe wake of trauma may impede access to affect andmemories about their traumatic experience, which maylimit emotional processing and recovery.[51] From anempirical perspective, there is much evidence thatperitraumatic dissociative reactions are very common,including emotional numbing, altered time sense,reduction in awareness of one’s surroundings, deperso-nalization, and amnesia.[10,13] Furthermore, there aremany studies indicating that peritraumatic dissociationis predictive of subsequent PTSD.[35,52–55] Despite thisevidence, there are several issues that raise significantconcerns about the emphasis currently placed ondissociation in ASD.

First, some recent meta-analyses have suggested that,in the majority of longitudinal studies, peritraumaticdissociation has not emerged as an independentpredictor of PTSD,[56,57] although others show that itdoes.[58] Second, a major reason for ASD not predictingPTSD adequately is the requirement that dissociativesymptoms be present, which precludes many high-riskpeople from being identified.[59] Third, there is muchevidence that dissociative responses are common underconditions of high stress and may not necessarily beassociated with psychopathology.[60,61] It should benoted, however, that this argument may also be madein reference to arousal, which may be normal in manycases but does not predict later PTSD.

There are several possible mechanisms that mayaccount for the mixed findings about peritraumaticdissociation and subsequent PTSD. First, dissociation



may play a role in PTSD development in someindividuals but not others. Diathesis stress models ofdissociative disorders suggest that only people whopossess dissociative tendencies respond to trauma withdissociative reactions.[62,63] This notion is supported byevidence that higher levels of hypnotizability have beenreported in people with ASD compared to those whohave a comparable ASR, but lack dissociative symp-toms.[64] Although both groups may have high risk fordeveloping PTSD, only the subset of people whopossess dissociative tendencies seem to respond withacute dissociative symptoms. Second, it is also possiblethat peritraumatic dissociation is associated withsubsequent PTSD because it is associated with otherknown risk factors for PTSD development. Forexample, there is documented relationship between ahistory of childhood trauma and subsequent dissocia-tion tendencies.[65] Moreover, childhood trauma is aknown risk factor for adult PTSD.[66] It is possible thatperitraumatic dissociation may be linked to PTSDbecause of its association with childhood trauma.[67]

Third, another potential role of dissociation is itsassociation with hyperarousal and extreme anxiety inthe acute phase after trauma exposure. Peritraumaticdissociation may be a consequence of elevated arousalthat occurs during trauma.[68] This interpretation isconsistent with evidence that the relationship betweenperitraumatic dissociation and acute stress depends onlevels of peritraumatic panic.[69,70]

Another problem with the DSM-IV definition ofdissociation was that it stated that dissociation in ASDcould occur ‘‘either during or after experiencing thedistressing event.’’ The ambiguity concerning the timeframe for dissociation is problematic because transientdissociation (peritraumatic dissociation) and persistentdissociation can lead to contrary predictions concerningoutcome. Cognitive models of trauma would predictthat persistent dissociation would be maladaptive andwould be associated with subsequent PTSD, because itimpedes retrieval of emotional memories that arerequired for adaption.[71] In contrast, transient dis-sociation at the time of the trauma could be a normalresponse under stress, and even protective because itmay limit the encoding of trauma of experiences. Inthis context, it is worth noting that persistent dissocia-tion is more predictive of ASD[72] and subsequentPTSD[73] than dissociation that only occurs at the timeof the traumatic experience. Similarly, a recentprospective study found that persistent dissociationwas a stronger predictor of subsequent PTSD thandissociation occurring immediately after the trauma.[35]

This pattern accords with evidence that much peritrau-matic dissociation is transient. For example, one studyfound that the vast majority of trauma survivors whoexperienced dissociative reactions at the time of thetrauma did not develop pathology, and their dissocia-tive symptoms did not persist beyond the trauma.[74]

However, the DSM-IV definition of ASD providessome protection against this problem by requiring that

symptoms ‘‘last for a minimum of 2 days’’ (p. 472).There is some ambiguity about the transient andpersistent nature of dissociation in ASD becausewhereas it does require a minimum of 2 days, it alsostates that dissociation may occur during or after thetrauma. There seems to be inadequate specification ofthe exact dissociative symptoms described in ASD.Although studies of chronic samples have found thatdissociative symptoms load onto distinct clusters,[75]

this has not been found to be the case in recentlytrauma-exposed individuals. For example, one study ofacute dissociative responses reported that 85% ofindividuals who reported lack of awareness of theirsurroundings also report derealization.[76] Further-more, it seems repetitive to conclude that a traumatizedindividual suffers amnesia if that same individual didnot adequately encode an event because of reducedawareness. However, although failure of encodingcould result in amnesia, it is a different problem thanretrieval difficulty, especially if amnesia is potentiallyreversible. Dissociation in the acute phase may func-tion differently than more chronic dissociation. Theseissues suggest that the DSM-IV definition of dissocia-tion may require greater delineation of dissociativesymptoms to ensure that strongly overlapping con-structs are not being assessed multiple times. In thiscontext, it is worth noting that a recent factor analysisof the Peritraumatic Dissociative Experiences Ques-tionnaire[68] found two distinct factors: Lack ofAwareness and Derealization.[77] Whereas Lack ofAwareness was not associated with ASRs, Derealizationwas. This pattern suggests that dissociative symptomsinvolving altered perceptions of self or one’s surroundsmay reflect more severe stress reactions than alterationsin attention.

Taken together, these data suggest that dissociationdoes not warrant the central place in ASD that it hasheld. Nonetheless, it is clearly an important emotionalresponse that many people do experience, and it canoften be associated with severe reactions. The majorproblems with its prominence in ASD seems to be (a)mandating its presence in order to diagnose ASD,although as noted above, dissociative responses may befrequent in the acute aftermath of trauma, (b) using itto predict subsequent PTSD, which is a secondary andnot a primary purpose of the disorder, (c) artificiallydistinguishing between overlapping dissociativeresponses, and (d) loosely combining dissociationoccurring at the time of the trauma and in thefollowing period. Future iterations of acute dissociativedefinitions need to more specifically operationalize thephenomena and specify the timeframe of the defineddissociative response. Despite these criticisms ofcurrent definitions of peritraumatic dissociation, thelimitations of acute dissociation in predicting subse-quent PTSD are also applicable to other ASDsymptoms. As noted above, even when the dissociationcluster is not required, subsyndromal ASD is still only amodest predictor of PTSD. Nonetheless, the presence

806 Bryant et al.


of dissociative symptoms in many trauma survivorssuggests these reactions need to be considered amongthe constellation of acute stress responses.

DOES THE ASD FACILITATEEARLY INTERVENTION

AFTER TRAUMA?One of the potential benefits of early identification

of people at high risk for PTSD development is theopportunity to provide secondary prevention to limitthe subsequent disorder. There is now considerableevidence that abridged forms of cognitive behaviourtherapy (CBT) for people with ASD is efficacious inreducing subsequent PTSD.[78–83] This evidence isconsistent with findings that providing CBT survivorswith PTSD in the first few months after traumaexposure prevents longer term problems.[84–86] Thesefindings do indicate that identifying people shortlyafter trauma with ASD/acute PTSD and providingthem with trauma-focused CBT is beneficial inreducing subsequent PTSD. Two implications of thisevidence emerge for DSM-V. First, this evidencehighlights the utility of having a means of identifyingpeople who are high risk for PTSD and can be treatedin the acute phase; the ability to identify people whoare high risk, however, may not necessarily require adiagnostic category. There may be other means tooptimally identify people who can benefit from earlyintervention (reviewed above). Second, these successfulstudies have focused on exposure-based interventionsfor people who suffer anxiety. In the context of theconsideration that ASD may be broadened to considerother emotional reactions (e.g., depression, anger,guilt, somatic reactions, dissociation, etc.), there aresignificant issues for treatment planning for these acutepresentations. For example, whereas there is strongevidence for CBT to target anxiety-based presenta-tions, there is no equivalent evidence for managingearly responses to trauma that primarily involves otherresponses, such as anger, depression, or guilt reactions.Although evidence-based interventions exist for thesevarious posttraumatic reactions, they may not requireor respond well to exposure-based treatments that arethe hallmark of treating ASD/PTSD. This is an issuethat needs to be recognized if considering an expansionof the fear/anxiety focus of the current definition ofASD.

ROLE OF SUBJECTIVEEMOTIONAL STRESSORS (A2)

IN ASDAs with PTSD, in order to meet the Stressor (A)

Criterion in the current definition of ASD, individualsexposed to threatening events (A1) must also experiencean intense subjective (A2) reaction characterized as

‘‘fear, helplessness, or horror.’’ In DSM-IV, A2 wasincluded in ASD (and PTSD) to more specificallyidentify people who had a negative reaction to atraumatic event rather than simply survive the experi-ence. The utility of the A2 criterion has beenchallenged by a series of studies focusing on PTSDbut have relevance to the role of A2 in ASD. One studyfound that intense levels of acute postexposure fear,helplessness, and horror were weakly predictive ofPTSD 6 months later.[87] Furthermore, other post-traumatic emotional reactions (such as anger or shame)also predicted PTSD. Finally, a small number of peoplewho denied postexposure A2 emotions also met PTSDcriteria at 6 months. Another study reported thatwithin a sample of A1 exposed individuals who went onto meet PTSD B-F criteria, a substantial minority(23%) failed to receive a PTSD diagnosis because ofthe absence of A2.

[88] Furthermore, there were nodifferences with regard to B-F symptom severity orimpairment between the A2 positive and A2 negativecohorts examined among a community sample of 6,104adults with a history of trauma exposure, and asubstantial minority (24% males and 19% females)failed to meet criterion A2.[89] There is also evidencethat only helplessness, but not fear or horror, iscorrelated with posttraumatic symptomatology.[90]

Supporting this accumulating evidence are reportsthat the presence of A2 had no effect on PTSDprevalence in the DSM-IV Field Trials[91] and in asample of older male military veterans.[92] These resultswere replicated by Karam et al. (submitted, underreview), regarding data from 102,846 respondents tothe WHO World Mental Health Survey Initiative, whofound that only 1.4% of respondents who met all otherPTSD criteria failed to meet the A2 criterion. Based onsuch findings, a number of investigators have called forthe elimination of the A2 criterion because of its poorpositive predictive value, and it does not enhanceidentification of people who will develop PTSD. Onthe other hand, a consistent finding from three studiesis the negative predictive value of A2.[87,91,92] In otherwords, people who do not exhibit an intense posttrau-matic emotional reaction are unlikely to developPTSD.

It has been suggested that the context for acuteposttraumatic reactions should be expanded beyond the‘‘fear, helplessness and horror’’ derived from a fearconditioning model of PTSD. For example, panicattacks have been one distinctive reaction that hasreceived attention. In the DSM-IV Field Trials, thepredominant indicator of posttraumatic distress was apanic reaction consisting of two components: ‘‘panic-physiological arousal’’ and ‘‘other panic symptoms’’(such as trembling, shaking, tachycardia, and fear ofdying), rather than A2 symptoms.[91] This accords withproposals that the physical and cognitive symptoms ofpanic mediate dissociation, as well as (A2) fear,helplessness, and horror. Other investigators havesuggested that the focus should be on the positive



predictive value of a fright reaction[93] or peritrau-matic autonomic activation.[94]

As noted earlier, a number of investigators[95] haveargued that other strong peritraumatic emotions arealso associated with PTSD, such as sadness, grief,anger, guilt, shame, and disgust. The DSM-IV FieldTrial observed that people could deny A2 (fear, help-lessness, or horror), as well as a panic reaction butreport confusion, negative affect, embarrassment, anddisgust.[91] Such a wide spectrum of posttraumaticreactions calls into question the utility of limiting A2 tothe fear conditioning model. The DSM-IV does notconsider other emotions, such as anger and rage, whichare experienced during fight rather than flightresponses, shame if an individual is made to enduredegradation or guilt if there is a violation of one’s moralbeliefs or ethical standards (Resick and Miller, in press).Finally, military and emergency medical personnel (forexample) often recall that they did not experience anyacute A2 or other emotional reaction in the immediateaftermath of trauma exposure. Rather, they report thattheir ‘‘training kicked in’’ as they carried out theirresponsibilities.[96,97]

CROSS-CULTURALCONSIDERATIONS FOR ASD

Whereas there is some evidence on cross-culturalmanifestations of ASRs, there is very little cross-cultural work on the predictive power of ASD.Comparing prevalence across studies for ASD isdifficult because (a) studies have used different assess-ment tools (ranging from validated measures to existinginstruments for PTSD that have been amended toindex ASD criteria but have not been validated), and (b)assessed patients from very different types of trauma.Generally speaking, most Western studies have focusedon survivors of traumatic injury because these areconvenient samples that can be located in hospitals;several studies from non-Western settings have mea-sured reactions to war or massive natural disaster.These different contexts result in major confoundsbetween culture and severity and type of traumaticexperience. A further possible confound in comparingsettings is the timeframe adopted by DSM-IV. ASD isdefined as the satisfaction of the symptom criteriabetween 2 days and 4 weeks after the traumatic event.This definition implicitly presumes that the traumaticevent has a discrete onset and offset, such as a motorvehicle accident or assault. In contrast, in the case ofpeople responding to a massive natural disaster, civilconflict, or refugee relocation, these traumatic experi-ences can be experienced for months or years—in thesecases it is problematic to compare prevalence rates in asetting where the traumatic event is discrete comparedto ongoing. Highlighting the variability of ASDprevalence across trauma events is evidence thatASD has been identified variably following terrorist

attacks after 9/11 (9%),[98] motor vehicle accident(13–25%),[59] and witnesses to drive-by shooting(33%).[99] In terms of comparing prevalence, it is mostuseful to compare estimates across the same type ofevent. The most studied type of event is traumaticinjury. In this context, prevalence does vary acrosssettings. For example, prevalence of ASD followingtraumatic injury has been reported in populations inAustralia (1,[100] 6,[101] 13,[22] and 14%[23]), UnitedKingdom (21[25] and 10%[35]), Switzerland (4%[102]),Germany (6%[43]), and Japan (9%[31]). These variablerates highlight that the prevalence rates do vary acrosssettings, even when the trauma type is held constant,although there is inevitable variability across studies instressor severity. Although most injury studies convergeon prevalence rates between 6–10%, there are sig-nificant outliers (i.e., 1% in Australia and 4% inSwitzerland, and up to 21% in the United Kingdom).This variability suggests that even among Westernsettings, the ASD prevalence varies.

In terms of prediction, across most studies there isconvergence that whereas the majority of people whomeet criteria for ASD subsequently develop PTSD,most people who develop PTSD do not initially meetcriteria for ASD.[59] This pattern is reflected acrosscultures insofar as ASD has modest sensitivity inidentifying people who will subsequently developPTSD in Australia, the United Kingdom, the UnitedStates, Switzerland, Germany, Norway, and Japan.

The hallmark feature of ASD is dissociation. Therole of dissociation is complicated in cross-culturalcontexts because dissociative states have differentconnotations in different cultures. It is worth notingthat general dissociation levels differ across racialgroups; for example, African-Americans and Asian-Americans report higher rates of dissociation thanwhite Americans.[103] Whereas DSM-IV presumes thatperitraumatic dissociation is a maladaptive responsethat is a precursor to psychopathology, many differentcultures perceive dissociative states in spiritual orreligious frameworks that may be considered adap-tive.[104] For example, the Candomble religion in Brazilperceives dissociative states as part of a spiritual lifehistory that needs to be narrated for self-healing.[105]

Several studies have reported that depersonalization isreported more often in Western settings than Columbia[106]

and Peru.[107] It has been suggested that, whereas inindividualistic societies (i.e., Western societies) havinga detached view of oneself is regarded as aberrant, incollectivist societies it is common to view oneself inrelation to one’s surrounds. Although dissociative statescan reflect maladaptive reactions across many cultures,it is premature to presume that dissociative states aftertrauma are indicative of poor adjustment in differentcultures until appropriate studies are conducted. Itshould be noted that the same could be said of fear,anxiety, sadness, and other responses that can beappropriate and adaptive in some contexts and mal-adaptive in others.

808 Bryant et al.


From a cross-cultural perspective, there may alsoproblems in presuming a fear circuitry perspective withASD that focuses on a narrow definition of themanifestation of anxiety. Some societies have reportedacute reactions that extend beyond these responses. Forexample, a study in the collectivist society of Micro-nesia found that the majority of youth exposed totraumatic stress responded with s’a’aw, which is a termthat fuses anger with fear and reflects the negativeemotional reaction to youth feeling that their standingin their local community was threatened.[108] Focusingspecifically on fear in the sense of fear circuitrydescribed could omit this ASR.

There is considerable evidence that ASRs arecharacterized by panic attacks.[109] Although there isnot a significant body of evidence pertaining to panic inthe acute phase after trauma, there is much evidenceconcerning the nature of panic attacks in different cultures.It is reasonable to conclude that these culturallyspecific features of panic attacks in different cultureswill apply to posttraumatic panic in the acute phase.For example, ataques de nervios have been documentedin Dominican and Puerto Rican people, which hasshown that although this constructs overlaps withpanic, it is not identical.[110] Whereas ataques de nerviosshares features with panic attacks (fear of losingcontrol, dizziness, fear of dying), there are otherfeatures not included in DSM-IV definitions of panicattacks (e.g., screaming, hitting out). Much work onataques de nervios has focused on the overlap withataques de nervios and panic disorder; however, therelevant issue for ASD is the breadth of description ofacute reactions of panic attacks that does not limit it tostrict panic disorder-type panic attacks. Similarly, therehas been much work done on panic attacks inCambodians (khyal), which involves a perception thata ‘‘wind’’ can enter the body in the diaphragm and risethrough the body and cause a range of symptoms,including shortness of breath, tinnitus, dizziness,soreness in the neck, and catastrophic fears for oneswell-being.[111,112] Rather than specify the exact natureof the panic symptoms associated with Cambodianreactions, it is sufficient to note that culturally specificdescriptions of panic should be applied to ASD becausepanic attacks (as distinct from panic disorder) arecommon in the acute phase after trauma.

ASD currently requires marked avoidance to satisfycriteria. This has conceptual overlap with emotionalnumbing, which is described as one of the dissociativesymptoms. It is important to note that certain Asiancultures explicitly discourage emotional displaysbecause it may lead to adverse consequences. Forexample, people from Bali may adopt a ‘‘smooth’’facade following trauma to mask emotional distress;this is adopted to avoid personal illness, harm to others,and harm to the spirits of lost loved ones.[113] Similarly,the Toraja in Indonesia avoid strong emotions which iscommonly regarded as adaptive, because intenseemotions are considered to be linked to poor health

outcomes.[114] To presume that all forms of avoidanceare markers of impaired emotional processing and aremaladaptive may ignore important local culturalstandards of coping. At this point, there is insufficientdata to inform us about the extent to which differentforms of avoidance are adaptive or maladptive acrosscultural settings.

TIMEFRAME FOR ASD

In DSM-IV, ASD could be diagnosed between 2 daysand 4 weeks following the traumatic event. There wasno sound evidence for the minimum 2-day delaybetween the onset of the traumatic event and thesymptoms. There is concern that diagnosing peoplewithin 48 hr of an event may identify many traumasurvivors who are experiencing transient stress reac-tions that will subsequently abate in the following days.In terms of the timeframe, the available evidence pointsto extending the current minimum delay from 2 days toa longer timeframe, to reduce the likelihood of falsepositive diagnoses; that is, by classifying people assatisfying ASD who may no longer display thesesymptoms 1 or 2 days later. There is a need to find abalance between introducing the diagnosis too early,yet ensuring that highly distressed people can receivediagnosis and treatment as soon as they need it. Thereis very little evidence to guide DSM-5 regarding theoptimal timeframe, because this decision is largelyinfluenced by situationally specific factors and by theposttrauma environment. It is highly probable thatASD reactions will be higher when current threat isstill present relative to when the threat has passed. Forexample, one study reported PTSD prevalence of 99%in Sierra Leone; however, this study was conducted inthe context of active civil unrest and direct threat torespondents.[115] It would be useful to study datasetsthat have assessed ASRs at different timeframeswithin the initial weeks following trauma exposure,because this can shed light on the trajectory of acutesymptoms over the initial weeks, which would providesome guidance on the optimal number of symptomsrequired to identify people who are likely to be sufferingacute symptoms beyond the immediate period.

DISTINCTION BETWEEN NORMALAND PATHOLOGICAL STRESS REACTIONS

One of the major challenges for a diagnosis of ASD isto operationally distinguish between normal andpathological stress responses to a traumatic event. Asnoted above, acute posttraumatic stress reactions arevery common and the majority of these subside withina short timeframe. If the new aim of ASD is to identifysevere ASRs, how does one quantify severe orpathological stress reactions? It is important to notethat the underpinning rationale of this proposeddiagnosis is not to predict longer term disorder, butto facilitate treatment for those suffering significantdistress and whose response suggests that this distress



may be interfering sufficiently or distressing the personexcessively such that treatment may facilitate recovery.In this sense, it may be more appropriate to describethe ASD construct in terms of severity of ASR ratherthan ‘‘psychopathology.’’ Several criteria may beconsidered in operationalizing the distinction betweensevere and less severe reactions. Is a requisite numberof acute symptoms associated with impairment offunctioning, as described in most DSM disorders?This is a problematic criterion to apply to ASD becauseit is often difficult to measure functioning in the weeksafter trauma, because social disruptions, environmentalupheaval, or changing medical status may limit scopefor measuring functioning accurately. Another possibi-lity is to define the required number of symptoms inorder to identify a limited proportion of individuals. Itwould be erroneous to define ASD in a liberal fashionsuch that the majority of trauma survivors met criteria,because it is well documented that the majority oftrauma survivors, even in the acute phase, adapt in theweeks from the severe levels of distress that may beinitially experienced. Ultimately, the number of symp-toms that should be required to meet an ASD diagnosisneeds to be empirically determined to ensure that (a)only the minority of trauma survivors are captured bythe diagnosis, and (b) the symptoms are likely todescribe marked stress responses that will be assisted bytargeted intervention.

UTILITY OF AN ASD DIAGNOSIS

In considering the utility for the ASD diagnosis, it isimportant to consider the conceptual, empirical, andpractical bases for such a diagnostic category. In termsof conceptual issues, the ASD diagnosis has beencriticized because the major distinguishing factor ASDand PTSD is the duration of symptoms.[4,5] Onerationale for retaining the ASD diagnosis is to formallydescribe the severe posttraumatic stress that somepeople experience in the initial month after traumaexposure without labeling them as suffering PTSD.There has justifiably been a reluctance to describesevere stress reactions as PTSD because many cases inthe acute phase will be transient. The issue that has tobe resolved is the manner in which these reactions aredescribed. Distinguishing syndromes according to atimeframe can be justified by acknowledging thatdifferent assumptions underlie this distinction: whereasPTSD is presumed to be a disorder that persistsbeyond a timeframe when the majority of people willexperience remission of severe reactions,[6,7] ASD isrecognized as a potentially transient disorder that mayor may not develop into PTSD. Although theargument could be made that PTSD could include an‘‘acute’’ subtype or specifier, this could artificiallyelevate the prevalence rates of PTSD.

The question may be asked: why do we need theASD diagnosis? If the predictive role of ASD isabandoned, what is the need to describe severe acute

reactions? A major rationale for the inclusion of ASD isto provide health care rebates for US citizens. At aservice delivery level, this has been identified asimportant in order for many people, who suffer distressin the acute phase after a trauma, to receive a formaldiagnosis that will allow them to receive compensablehealth care services for mental health problems. Thetimeframe of 1 month before PTSD may precludesome survivors from receiving diagnosis and health-care. In this context, we need to acknowledge thatDSM-5 is not driven simply by theoretical or scientificpriorities but also by practical issues faced by USpractitioners. In this sense, DSM-5 is primarily aUS product that at times may have less relevance tointernational communities that may not share the samehealth care financing problems as the United States.A cogent argument could be made that if there was noneed for a diagnosis to facilitate access to appropriatemental health services in the United States, the needfor the ASD diagnosis would markedly diminish.Nonetheless, the expectation is that the proposeddefinition of ASD will provide clinicians anywhere toidentify the more severely distressed survivors oftrauma who may benefit from early interventions thathave proven efficacy with ASD patients.

LITERATURE-INFORMEDRECOMMENDATIONS

1. There is strong evidence that ASD does not identifythe majority of people who subsequently developPTSD, in that it is sensitive but not specific.Accordingly, the definition of the diagnosis shouldnot necessarily be shaped by factors that arepredictive of PTSD. Current studies indicate thatvariations of the ASD diagnosis do not adequatelyaddress the poor predictive capacity of ASD.Accordingly, it is useful to distinguish between thegoals of describing acute reactions from predictingpeople who will develop chronic disorder. In light ofthe reviewed evidence that ASD does not adequatelyidentify the majority of people who subsequentlydevelop PTSD, it is proposed that it’s predictive rolebe abandoned. To that end, it is more appropriate toconceptualize the ASD diagnosis as a means todescribe ASRs that are severe enough to warrantclinical attention. In many health systems (especiallyin the United States), receiving a diagnosis canfacilitate access to mental health services, and so theASD diagnosis may allow people in need of mentalhealth services to receive adequate care. In thissense, ASD may be conceptualized as severe distressin the acute phase but without the presumption thatit will develop into subsequent disorder. This canactually be conceptualized as a benefit of thisdiagnostic category.

2. An outstanding issue is the extent to which ASDshould focus on fear/anxiety/posttraumatic stress

810 Bryant et al.


responses or should be broadened (in a mannersimilar to ASR) to encompass the range of emotionalproblems trauma survivors can experience in theacute phase. The attraction of the latter option isthat it will be applicable to most people who sufferanxiety, depression, grief, guilt, anger, or somaticreactions. The problem with this option is that itdoes not necessarily translate to specific treatmentoptions, which the current ASD formula does.A parsimonious solution seems to describe peoplein the acute phase who present with predominantposttraumatic stress responses as ASD (and who willthen receive targeted intervention), and AdjustmentDisorder can be applied to other trauma survivorswho display other forms of distress.

3. If the goal is to describe acute anxiety reactionsfollowing trauma, the remaining question is todefine the requisite symptoms. At present, the ASDcriteria are clustered into four categories (dissocia-tion, re-experiencing, avoidance, and arousal), andone needs to display reactions in each category tomeet criteria. The current data suggest that there isconsiderable heterogeneity in acute responses andbeing prescriptive about the specific symptoms maybe difficult and exclude those who report anxiety-related distress in different forms. In this sense, itneeds to be recognized that, whereas chronic formsof PTSD symptoms do tend to cluster intorecognized groupings of symptoms, this may developas time progresses. Accordingly, it may be moreappropriate to describe ASD in terms of peoplesuffering a requisite number of symptoms, but notprescribing that they need to be from specificclusters. For example, current data indicate thatmany patients respond in the acute phase withdissociative responses, but comparable numbersdisplay acute stress in the absence of dissociation.Requiring a requisite number of symptoms mayincrease identification of acute distressed peoplewho may benefit from treatment by acknowledgingthe diversity of acute posttraumatic stress responses.

4. The remaining question is what potential symptomsshould comprise the ASD diagnosis and how many ofthese should be required to meet diagnostic threshold.Across studies, there is convergent evidence thatre-experiencing symptoms are a hallmark feature ofanxiety responses in the initial period after trauma.This observation is consistent with fear conditioningmodels of trauma response,[116] and accords with thefinding that the absence of these symptoms in theacute phase is highly predictive of the absence ofacute or chronic anxiety.[58] Reviewing the literature,however, indicates that re-experiencing needs to bedefined somewhat broadly because it does not alwaysinvolve repeated intrusive memories. Re-experiencingfollowing the trauma may include memories, night-mares, flashbacks, or psychological, somatic, orbehavioral reactivity to reminders. This is ultimatelyan empirical question that requires calculating the

requisite symptoms reported by patients in the acutephase to capture those patients who also displaymarked distress on independent measures. There is aneed to limit overdiagnosis, insofar as it would be amistake to describe all stress reactions in the acutephase as ASD when they may be short-term transientresponses that may not require mental health inter-vention. In this context, it is worth emphasizing thatthe ASD diagnosis in DSM-V may be conceptualizedas an acute response that may be temporary andresolve rapidly or may continue to PTSD. Unlikemany other disorders, ASD is not likely to be tested inthe context of field trials because it requires identify-ing people who have very recently been exposed totraumatic events. On the other hand, there are manydatasets in the field in which researchers have assessedASD symptoms. A potential means to clarify theoptimal number of symptoms would be to calculatethe requisite number of symptoms that patients reportin the acute phase that optimally captures thosepatients who are reporting significant distress (asmeasured by independent measures of posttraumaticstress/anxiety).

5. In terms of timeframe, it will be important in text tohighlight that clinicians need to evaluate the extentof the disorder in relation to which the threat haspassed or if the person is still living in a highlystressful environment (e.g., soldier in combat orsurvivor of massive disaster). At this point in time, itmay be appropriate to extend the delay from 2 to 3days to not only minimize overdiagnosis, but also toensure that distressed people are able to be assessedand treated in the acute phase.

PROPOSED ASD DIAGNOSTIC CRITERIAFOR DSM-V

The rationale for the proposed diagnostic criteria isto identify trauma survivors in the initial monthfollowing trauma who are displaying marked fear/anxiety responses and may benefit from mental healthservices. The focus of the diagnosis is on acuteposttraumatic stress, because the disorder is concep-tualized as a diagnosis of early PTSD and because thereis a strong evidence base for intervening in cases thatare characterized by fear/anxiety (rather than morediverse emotional responses that can be described byAdjustment Disorder).

This revision is a radical shift from the DSM-IVdefinition. This shift is justified by that (a) the ASDdiagnosis was new to DSM-IV and at the time therewas very little evidence to substantiate the definingsymptoms, (b) there is now strong evidence that ASD isnot the optimal means to identify trauma survivors whoare high risk for PTSD, and (c) ASD is betterconceptualized as a description of severe ASRs. Theproposed revision will comprise the major changes tothe DSM-IV definition of ASD: (a) modifying theStressor definition to eliminate A2, and (b) requiring a



minimum number of symptoms to present, but thesedo not need to be from prescribed clusters. Thespecific proposal is:

1. Criterion A1 (stressor) will probably not changesubstantially. The language of A1 has been revisedto emphasize that qualifying events must involvedirect exposure to actual or threatened death,serious injury, or a threat to the physical integrityof others. The most controversial aspect of theDSM-IV A1 Criterion is having been ‘‘confrontedby’’ traumatic events. The proposed revision limitssuch ‘‘confrontation’’ to learning about the trau-matic exposure of a close friend or loved one orlearning about aversive details of unnatural deaths,serious injury or serious assault to others. Thisincludes learning about the homicide of a familymember, learning about the gruesome death orgrotesque details of rape, genocide, or otherabusive violence to others.

2. Criterion A2 (subjective sense of fear, helplessness,or horror) will be eliminated because there is littleevidence to support it.

3. B1 (sense of numbing) is largely unchanged butmoved to B5.

4. B2 (reduction in awareness) is deleted becauseearlier studies indicate that it overlaps largely withother dissociative symptoms.

5. B3 (derealization) and B4 (depersonalization) arecombined into B6 because of evidence that deperso-nalization and derealization are strongly overlapping.

6. B5 (dissociative amnesia) is largely unchanged andbecomes B7.

7. The re-experiencing symptoms (previously ClusterC) are now delineated as specific symptoms inaccordance with considerable evidence concerningASRs. These symptoms are intrusive memories (B1),nightmares (B2), flashbacks (B3), and psychologicaldistress/physiological reactivity on reminders (B4).

8. The avoidance symptoms (previously Cluster D) arenow delineated as two separate symptoms: avoid-ance of thoughts, feelings, and conversations (B8)and avoidance of situations (B9). This will refine theearlier description of ‘‘marked’’ avoidance.

9. The arousal symptoms (previously Cluster E) arenow delineated as five separate symptoms to refinethe earlier description of ‘‘marked’’ arousal: sleepdisturbance (B10), hypervigilence (B11), irritability(B12), startle reaction (B13), and agitation (B14).

10. The major revision is that rather than requiringendorsement of each of the four clusters, the newcriteria recognize that there is heterogeneity inacute stress responses, and thus it requires aspecific number of symptoms without requiringany particular symptoms to be present. At thisstage, the evidence indicates that requiring peopleto satisfy specific clusters may not be appropriatein the acute phase because current evidence that

satisfying the four ASD clusters is restrictive ofpeople satisfying acute stress.[4,7] It is premature todefinitively conclude that there should not be arequirement that specific symptoms/clusters bepresent in order to satisfy ASD diagnosis becausethe available datasets have not been exhaustivelystudied. There is a theoretical reason thatre-experiencing may be mandatory because fearconditioning models posit that these symptomswill drive all other reactions; however, this has yetto be empirically validated across datasets.

The proposal described here is tentative and isdependent on comprehensive analyses of at least12 existing datasets that have collected ASD responsesfrom numerous countries (including datasets from theUnited Kingdom, the United States, Israel, Japan, TheNetherlands, Norway, and Australia). The eventualcriteria need to be empirically validated across thesedatasets to ensure that the structure and number ofsymptoms is consistent across settings and accuratelyidentifies the minority of people with severe stressreactions that would indicate early intervention.

At this point, it is tentatively proposed that 8 out ofthe 14 symptoms be present to make an ASD diagnosis.The tentative proposal of 8 from 14 symptoms wasderived from two steps. The 14 potential symptomswere derived from the current list of ASD symptoms,with the combination of several symptoms that havebeen shown in earlier studies to be strongly over-lapping; for example, reduced awareness was deletedbecause of strong overlap with other symptoms,and derealization was combined with depersonali-zation because of the theoretical and documentedoverlap between these symptoms.[8] Three large-scaledatasets (one unpublished dataset from Israel and twopublished datasets from the United Kingdom[9] andAustralia[10,11]) were analyzed to determine an optimalcut-off to identify 20% of recently trauma-exposedpeople. We emphasize that this decision–rule wasadopted only to calculate an approximate number ofsymptoms that could be tested (and modified) in morecomprehensive analyses of more datasets. On this basis,it was noted that 8 of the potential 14 symptoms tendedto capture approximately 20% of the samples. Accord-ingly, we propose that this requisite number ofsymptoms should be tested across datasets.

PROPOSED ASD/PTSD SUBTYPEOF ADJUSTMENT DISORDERS

A new ASD/PTSD subtype of adjustment disorderhas been proposed for DSM-5. It is much more specificthan other adjustment disorder subtypes and wouldprovide a subsyndromal diagnostic option for indivi-duals who exhibit many posttraumatic ASD or PTSDsymptoms but who fail to meet full ASD/PTSDdiagnostic criteria. With respect to ASD, for example,

812 Bryant et al.


it would provide a much more specific diagnostic nichefor individuals who present with less than the requisiteeight ASD symptoms but who are clearly exhibiting aclinically significant assortment of posttraumatic

re-experiencing, dissociative, avoidance and/or arousalsymptoms (Table 2).

The ASD/PTSD subtype will make it possible toidentify people with subsyndromal ASD (and PTSD),

TABLE 2. New diagnostic criteria for acute stress disorder for DSM-5

Criterion A. The person was exposed to one or more of the following situations� Experienced an event or events that involved a threat of death, actual or threatened serious injury, or actual or threatened physical or sexual

violation of himself or herself� Personally witnessed an event or events that involved the actual or threatened death, serious injury, or physical or sexual violation of others� Learned of such harm coming to a close relative or close friend� Or underwent repeated or extreme exposure to aversive details of unnatural death, serious injury, or serious assault or sexual violation of

othersWitnessed exposure or exposure to aversive details does not include events that are witnessed only in electronic media, television, video games, movies,

or pictures

Criterion B. Eight (or more) of the following symptoms are currently present that were not present before the traumatic event or have worsenedsince(1) A subjective sense of numbing, detachment from others, or reduced responsiveness to events that would normally elicit an emotional

response(2) An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing)(3) Inability to remember at least one important aspect of the traumatic event that was probably encoded (i.e. not due to head injury, alcohol,

drugs)(4) Spontaneous or cued recurrent, involuntary and intrusive distressing memories of the event(5) Recurrent distressing dreams related to the event(6) Dissociative reactions in which the individual feels or acts as if the traumatic event were recurring(7) Intense or prolonged psychological distress or physiological reactivity at exposure to internal or external cues that symbolize or resemble an

aspect of the traumatic event(8) Persistent and effortful avoidance of thoughts, conversations, or feelings that arouse recollections of the trauma(9) Persistent and effortful avoidance of activities, places, or physical reminders that arouse recollections of the trauma(10) Sleep disturbance (e.g., difficulty in falling asleep, restless sleep, or staying asleep)(11) Hypervigilence(12) Irritable, angry or aggressive behavior(13) Exaggerated startle response(14) Agitation or restlessness

C. Duration of the disturbance (symptoms described in Criterion B) occurs for 3 or more days and less than 1 month after the traumatic eventD. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioningE. The disturbance is not due to the direct physiological effects of a substance (e.g., medication or alcohol) or a general medical condition (e.g.,

traumatic brain injury, coma), and is not better accounted for by brief psychotic disorder

1. Shephard B. A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century. London: Johnathan Cape; 2000.2. Isserlin L, Zerach G, Solomon Z. Acute stress responses: a review and synthesis of ASD, ASR, and CSR. Am J Orthopsychiatry

2008;78:423–429.3. The dexamethasone suppression test: an overview of its current status in psychiatry. The APA task force on laboratory tests in psychiatry. Am J

Psychiatry 1987;144:1253–1262.4. Arana GW, Baldessarini RJ, Ornsteen M. The dexamethasone suppression test for diagnosis and prognosis in psychiatry. Commentary and

review. Arch Gen Psychiatry 1985;42:1193–1204.5. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull

2003;129:52–73.6. Harvey AG, Bryant RA. Acute stress disorder: a synthesis and critique. Psychol Bull 2002;128:886–902.7. Marshall RD, Spitzer R, Liebowitz MR. Review and critique of the new DSM-IV diagnosis of acute stress disorder. Am J Psychiatry

1999;156:1677–1685.8. Bryant RA, Harvey AG. Acute stress disorder: a critical review of diagnostic issues. Clin Psychol Rev 1997;17:757–773.9. Bryant RA. Early predictors of posttraumatic stress disorder. Biol Psychiatry 2003;53:789–795.

10. Harvey AG, Bryant RA. Dissociative symptoms in acute stress disorder. J Trauma Stress 1999;12:673–680.11. Brewin CR, Andrews B, Rose S, Kirk M. Acute stress disorder and posttraumatic stress disorder in victims of violent crime. Am J Psychiatry

1999;156:360–366.12. Bryant RA, Creamer M, O’Donnell ML, Silove D, McFarlane AC. A multisite study of the capacity of acute stress disorder diagnosis to predict

posttraumatic stress disorder. J Clin Psychiatry 2008;69:923–929.13. Bryant RA, Creamer M, O’Donnell ML, Silove D, McFarlane AC. A multisite study of the capacity of acute stress disorder diagnosis to predict

posttraumatic stress disorder. J Clin Psychiatry 2008;e1–e7.



to assess their symptom severity using standard ASD(or PTSD) assessment instruments, and to assesstreatment outcome utilizing interventions shown tobe effective for ASD (and PTSD).[117]

FINAL REMARKSThe proposed ASD criteria for DSM-V are tentative

at this stage. It is proposed that the tentative criteria betested across at least ten large-scale existing datasetsfrom different countries. The eventual criteria willneed to be an empirically determined set of symptomsthat distinguish severe from moderate acute anxietyreactions, which will need to be determined bymeasuring different symptom constellations againstindependent measures of distress or functioning. Thepossibility that a required cluster be mandatory for thediagnosis (e.g., re-experiencing) will also need to betested. It is expected that by comparing the endorse-ment of variable numbers and structure of symptoms,and by evaluating this response in relation to scores onmeasures of distress, a criteria set will be derived thatpermits identification of the minority of people in themonth after trauma that can benefit from trauma-focused interventions.

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